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Nursing's Unique Role in Care Coordination
Session NI1, February 11, 2019
Robin Newhouse, PhD, RN, Distinguished Professor and Dean
Indiana University School of Nursing
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Robin Newhouse, PhD, RN, NEA-BC, FAAN
Royalty: American Nurses Association
Co-author of Care Coordination: A Blueprint for Action for RNs
Conflict of Interest
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• Provide an in-depth overview of the concept of care coordination
• Outline the role of nurses and nurse informaticists in care
coordination
• Provide concrete examples of the value and impact of leveraging
information and technology to achieve care coordination
Agenda
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• Define care coordination
• Identify one action step you will take to advance your role in care
coordination
• Reflect on use of technology and information to achieve care
coordination in a clinical setting linking value and impact patient
care
Learning Objectives
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ANA and AAN Task Force (2014-2015)
Charge to the 2014 Care
Coordination Task Force
– Identify and prioritize the policy
options in the three policy and
framework briefs
– Develop strategies and a timeline
for implementation of the policy
options
– Propose suggested lead
organizations or entities for
implementation of the policy
options
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What do we know, and what can we do?
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Care Coordination is the deliberate….
“..synchronization of activities and information to improve health outcomes by
ensuring that care recipients’ and families’ needs and preferences for
healthcare and community services are met over time.”
National Quality Forum, 2014
“..organization of patient care activities between two or more participants
(including the patient) involved in a patient’s care to facilitate the appropriate
delivery of health services. Organizing care involves the marshalling of
personnel and other resources needed to carry out all the required patient care
activities and is often managed by the exchange of information among
participants responsible for different aspects of care.”
McDonald et al., 2014, p. 6
Care Coordination Definition
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Mechanisms for Achieving Care Coordination
McDonald et. al., 2014, p. 14
Coordination Activities
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Establish accountability or negotiate responsibility
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Communicate
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Facilitate transitions
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Assess needs and goals
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Create a proactive plan of care
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Monitor, follow up, and respond to change
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Support self-management goals
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Link to community resources
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Align resources to with patient and population need
Broad Approaches
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Teamwork focused on coordination
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Health care home
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Care management
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Medication management
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HIT-enabled coordination
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Care Coordination: Central to Achieving
U.S. Quality Goals
National Quality Strategy priority for improving health care quality, better
care, healthier people and communities, and lower cost
Agency for Healthcare Research and Quality [AHRQ], 2016, 2017
Nurses play an integral role in comprehensive care coordination - how can
we accelerate our contribution?
What do we know?
What’s trending?
What can RNs do?
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Six Actionable Care Coordination Issues for RNs
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• Patient, family, and caregiver engagement
• Competency and readiness
• Teams and teamwork
• Documentation and Health Information Technology (HIT)
• Quality and performance measurement
• Payment
Six Actionable Issues for Nurses
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Action Issue 1: Engaging Patients, Families,
and Caregivers in Care Coordination
• Choose and implement a visible and systematic
approach to engaging patients in your care
coordination practice.
• Use robust patient engagement tools and decision aids.
• Document and evaluate patient engagement activities.
• Advocate for patients, family members and caregivers
to serve on healthcare advisory committees and
boards.
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Action Issue 2: Demonstrating Competence and
Readiness for Care Coordination Practice
• Know nursing’s scope and standards for care
coordination.
• Recognize and name care coordination when you’re
doing it; educate patients, families, and team members
about nursing’s competency requirements.
• Explore continuing education opportunities and formal
degree programs to increase your knowledge and skill
in care coordination.
• Seek national certification when your practice meets
qualifications for specialty certification.
• Advocate for care coordination being provided by
competent professionals.
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Action Issue 3: Optimizing Teams and
Teamwork for Care Coordination
• Step forward on health care teams to lead care
coordination.
• Foster a practice culture and environment that supports
team members practicing to their full scope.
• Assist team members with identifying core
competencies for care coordination and the appropriate
team member to carry them out.
• Advocate for and lead competency-based evaluation of
care coordination interventions.
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Action Issue 4: Using Documentation and
HIT in Care Coordination
• Review EMR data elements and determine if care
coordination activities are captured.
• Talk with the chief nurse executive (CNE) or chief information
officer (CIO) to discuss future plans to add care coordination
data elements and patient-reported outcomes.
• Use established domains for informing HIT architecture for
care coordination.
• Determine which patient outcomes are available in the EMR.
• Identify the resources available to support the implementation
and evaluation of HIT that captures care coordination.
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Action Issue 5: Measuring Care Coordination
• Become familiar with care coordination measures.
• Identify and share measures that address gap areas for
nursing.
• Volunteer to serve on care coordination measurement
workgroups and committees.
• Advocate for new measures and funding.
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Action Issue 6: Understanding Payment in
Care Coordination
• Become familiar with the ANA and AAN policy priorities for payment
to be ready for dialogue with health care leaders, businesses,
insurers, and policy-makers.
• Be aware of and ready to discuss care coordination models with cost
effectiveness established.
• Document the care coordination components that require an RN or
APRN and those that do not in both established care coordination
models and those that are being evaluated locally.
• Collaborate with practice settings to disseminate, translate, and test
new nurse care coordination models in multiple settings with diverse
populations of patients.
• Engage in the policy debate on issues of payment reform at the
local, state, and policy levels to advance value-based nurse care
coordination.
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Role of Nurses and Nurse Informaticists
• Develop and test common data elements for care coordination
• Select and implement care coordination measures
• Evaluate care coordination patient, administrative and system
outcomes
• Assess patient portals applications for care coordination
• Develop decision aids to assist patients, families, caregivers and
clinicians
• Consult for interdisciplinary teams on strategies to measure care
coordination
• Create technology solutions to care coordination challenges
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Will nurses lead the way?
If not us…who?
Care Coordination for 21
st
Century Nurses
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References
Agency for Healthcare Research and Quality. (2016). 2015 National healthcare
quality and disparities report and 5th anniversary update on the National Quality
Strategy. AHRQ Pub. No. 16-0015. Rockville, MD: Agency for Healthcare
Research and Quality. Retrieved from
https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr1
5/2015nhqdr.pdf
Agency for Healthcare Research and Quality. (2017). About the National Quality
Strategy. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved
from http://www.ahrq.gov/workingforquality/about/index.html
Lamb, G. 2013. Care coordination: The game changer. Silver Spring, MD:
American Nurses Association.
Lamb, G., Newhouse, R., Beverly, C., Toney, D.A., Cropley, S., Weaver, C.A.,
Kurtzman, E., Zazworsky, D., Rantz, M., Zierler, B., Naylor, M., Reinhard, S.,
Sullivan, C., Czubaruk, K., Weston, M., Dailey, M., Peterson, C. (2015). Agenda
for Nurse-Led Care Coordination. American Nurses Association and American
Academy of Nursing, Washington, DC available at
http://www.nursingworld.org/DocumentVault/Health-Policy/ANAs-Policy-Agenda-
for-Nurse-Led-Care-Coordination.pdf.
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References
Lamb, G., Newhouse, R., Beverly, C., Toney, D.A., Cropley, S., Weaver, C.A., Kurtzman,
E., Zazworsky, D., Rantz, M., Zierler, B., Naylor, M., Reinhard, S., Sullivan, C., Czubaruk,
K., Weston, M., Dailey, M., Peterson, C. (2015). Task Force Members Policy Agenda for
Nurse-led Coordination. Nursing Outlook, 63(4), 521-530.
Lamb, G. & Newhouse, R. (2018). Care Coordination: A Blueprint for Action, American
Nurses Association. Silver Spring: MD.
McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., … Davies, S.
(2014). Care coordination measures atlas, version 4. Prepared by Stanford University
under subcontract to American Institutes for Research on Contract No. HHSA290-2010-
00005I. AHRQ Pub. No. 14-0037-EF. Version 4. Rockville, MD: Agency for Healthcare
Research and Quality. Retrieved from
https://www.ahrq.gov/sites/default/files/publications/files/ccm_atlas.pdf
National Quality Forum. (2014). Priority setting for healthcare performance measurement:
Addressing performance measure gaps in care coordination. Washington, DC: National
Quality Forum. Available from
https://www.qualityforum.org/Publications/2014/08/Priority_Setting_for_Healthcare_Perfo
rmance_Measurement__Addressing_Performance_Measure_Gaps_in_Care_Coordinatio
n.aspx
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• Abu-Rish Blakeney, E., Lavallee, D., Baik, D., Pambianco, S., O’Brien, K., Zierler, B.
(2018). Purposeful interprofessional team intervention improves relational coordination
among advanced heart failure care teams. Journal of Interprofessional Care, 27(1), 1-
9, doi: 10.1080/13561820.2018.1560248.
• American Academy of Nursing Care Coordination Edge Runners. Accessed January
13, 2019 at http://www.aannet.org/initiatives/edge-runners/carecoordination
• AHRQ, Care Coordination Measures Data Base. Accessed January 13, 2019 at
https://primarycaremeasures.ahrq.gov/care-coordination//Search
• Bates, D. (2015). Health Information Technology and Care Coordination: The Next Big
Opportunity for Informatics? Yearbook of medical informatics. 10(1), 11-14. doi:
10.15265/IY-2015-020.
• Rantz, M., Popejoy, L., Galambos, Cl, Phillips, L., Lane, K., Dorman Marek, K., Hicks,
L., Musterman., Back, J., Miller, S., Ge, B. (2014). The continued success of
registered nurse care coordination in a state evaluation of aging in place in senior
housing. Nursing Outlook, 62(4), 237-246. doi: 10.1016/j.outlook.2014.02.005
• Williams, J, Feero, W.G, Leaonad, D, Coleman, B (2017). Implementation science,
genomic precision medicine, and improved health: A new path forward? Nursing
Outlook, 65(1), 36-40. doi: 10.1016/j.outlook.2016.07.014.
Case Examples
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Contact information:
• newhouse@iu.edu
• Twitter handle RobinPNewhouse
• LinkedIn Robin Newhouse
Don’t forget to complete the online session evaluation
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